Hepatic tuberculosis presenting with extreme hyperferritinemia masquerading as adult-onset Still’s disease: a case report

Abstract

Introduction Isolated hepatic tuberculosis is an uncommon manifestation of one of the most common infections worldwide, caused by Mycobacterium tuberculosis. Extremely high serum ferritin, which is regarded as a marker of adult onset Still’s disease, has not been observed in patients with tuberculosis of the liver. We report a case of hepatic tuberculosis who presented with clinical criteria of adult-onset Still’s disease and extreme hyperferritinemia, which posed a diagnostic confusion. Case presentation Our patient was a 48-year-old Sri Lankan man who presented with fever, polyarthralgia and a generalized skin rash of three months duration. He had marked constitutional symptoms, oral ulcers, hair loss, anemia and hepatomegaly. Laboratory investigations disclosed an inflammatory syndrome, evidence of hepatic dysfunction, bone marrow suppression and a raised serum ferritin level of 34,674 ng/ml. A rapidly deteriorating course of illness prompted treatment based on a presumptive diagnosis of adult-onset Still’s disease until liver histology was available. The patient died of sepsis followed by multi-organ dysfunction. Later, the liver histology revealed tuberculosis. Conclusion Extrapulmonary tuberculosis, although well known to present with peculiar manifestations, has not been reported to be associated with extremely high levels of serum ferritin in immunocompetent individuals. Isolated hepatic tuberculosis presenting with clinical criteria of adult-onset Still’s disease is remarkable. Since tuberculosis remains a potentially curable disease, an awareness of its’ protean manifestations is essential.

A rare case of occult abdominal tuberculosis with Poncet′s disease mimicking Adult onset Still′s disease

“…As per our literature search, there has been only one case report of tuberculosis with extreme hyperferritinemia mimicking AOSD in which the patient had hepatic tuberculosis. [ 10 ] Such atypical manifestation of not so easily diagnosed abdominal tuberculosis in endemic areas can pose a major diagnostic challenge and delay the necessary treatment.…”

Disseminated BCG Infectious Disease and Hyperferritinemia in a Patient With a Novel NEMO Mutation

“…Such elevations are observed in some types of cancer, systemic onset juvenile rheumatoid arthritis, multiple erythrocyte transfusions, and hemophagocytic lymphohistiocytosis [8–10]. The patient received erythrocyte suspensions twice for anemia during follow-up, and transfusion-related liver iron accumulation was excluded by histopathology and MRI.…”

Refractory Adult Onset Still’s Disease

“…AOSD has been reported rarely as a cause of PUO [ 3 ]. AOSD may present with atypical and protean manifestations or may mimic other inflammatory disorders or chronic infections such as tuberculosis [ 4 ]. It may be complicated with HLH which carries a poor prognosis and high mortality, often because of delay in diagnosis and treatment [ 5 ].…”